Manslaughter, criminally negligent homicide, and other felony charges filed against paramedics in a Denver suburb will provide the public with a queasy close up look at not only the stresses weighing on medical first responders but also how complacent too many people have become as a crucial part of health care frays under fiscal pressures.

The case against Aurora Fire and Rescue paramedics Jeremy Cooper and Lieutenant Peter Cichuniec provides a grim view of municipal emergency medical services.

A grand jury, empaneled by the state attorney general, indicted the city paramedics and two Aurora police officers on an array of charges in the 2019 death of  Elijah McClain, a 23-year-old black man. He was walking home from a convenience store on an August evening, wearing a ski mask because, his parents said, he was an anemic, idiosyncratic individual and often felt cold.

The police would insist that his behavior was suspicious. They used progressively rough tactics to stop and apprehend McClain, a thin and bespectacled massage therapist. Officers’ attempts at restraint included a “carotid artery choke-hold” barred by law enforcement in many areas. After officers Nathan Woodyard and Randy Roedema had wrestled McClain to the ground and handcuffed him, he was vomiting and complaining he could not breathe.

A police claim of a suspect with ‘excited delirium’

Investigators say the paramedics arrived and failed to address McClain’s urgent medical distress. Instead, they were told by the police that McClain was experiencing “excited delirium.” That is a hotly debated description of an unproven condition in which individuals may exert extreme resistance to police during arrest.

The paramedics responded to the police comments by giving the 140-pound McClain 500 milligrams of  ketamine — more than 1.5 times the dosage recommended, based on his weight, of a drug better known as an animal tranquilizer and sometimes as a much-abused party drug. As NPR reported:

“The fire department is allowed to use the drug to sedate combative or aggressive people, but there’s a lack of police training, conflicting medical standards and nonexistent protocols that have resulted in hospitalizations and even deaths when it’s used during police encounters. Within five minutes, according to a federal lawsuit from McClain’s family, he stopped breathing. He died six days later after being declared brain dead and taken off life support.”

The grand jury indictment has led to charges against the paramedics for assault, “in addition to counts of recklessly causing bodily injury with a deadly weapon — the sedative ketamine,” NPR reported, adding, “In addition, the paramedics face assault counts related to ‘intentionally causing stupor, unconsciousness, or other physical or mental impairment or injury’ by administering ketamine to McClain without consent, for a purpose other than lawful medical treatment.”

The nonprofit, independent Marshall Project on criminal justice reported about excited delirium:

“Syndromes with similar characteristics but different names have appeared in scientific articles since the 1850s, according to the limited research available. Excited delirium didn’t emerge as a common diagnosis until the 1980s, with the rise in cocaine use. Some supporters of its use as a diagnosis say it’s a syndrome first responders must be trained to recognize, because it can cause people to die suddenly, leaving police wrongfully accused of excessive force. But here is where the issue becomes even more problematic … When authorities call in medical first responders, aka paramedics, should they administer powerful drugs in settings that often are harried, fraught with emotion, and in which they may lack the time or expertise to make a difficult and full evaluation of an individual’s health?”

NBC News earlier has noted:

“In Colorado, EMS providers are permitted to use ketamine for pain management and to treat a syndrome known as ‘excited delirium,’ but they must first obtain a waiver from the state health department. It is not uncommon for medics to use ketamine outside hospital settings to treat patients who appear agitated and may harm themselves or others, according to the state. Statewide, 427 people were given ketamine for agitation from August 2017 to July 2018, and about 20% of patients had to be intubated at a hospital, The Denver Post reported.”

Those figures may seem high. They may reflect not only weak or poor health treatment choices by medically trained personnel but also the huge pressures on them now. Those have only increased significantly due to the coronavirus pandemic.

Emergency medical response isn’t as it once was

Medical first responders have undergone big changes in recent times, as ProPublica, the Pulitzer Prize-winning investigative site reported. Sure, in many areas, taxpayers have footed the bills for the rising costs of urgent care, paying what can be steep salaries for highly trained paramedics in police or fire agencies. Governments, such as the District of Columbia, have grappled, too, with misuse and abuse of this costly emergency response, including by 911 callers asking for assistance with minor issues like rashes, coughs, or a tweaked ankle.

For many jurisdictions, however, a far different financial response has emerged — privatizing emergency medical response, as ProPublica found in parts of sprawling Los Angeles County and elsewhere:

“In Los Angeles County, as in many parts of the U.S., for-profit companies operate the ambulance system. The contract for the north part of L.A. is held by American Medical Response, the largest ambulance company in the nation. Along with paramedics from the fire department, EMTs employed by American Medical Response handle all of the emergency medical calls in this ‘exclusive operating area,’ a roughly 1,500-square-mile dominion that includes the cities of Palmdale and Lancaster, a smattering of quarries and aerospace factories, and swaths of the Mojave Desert. Spending as little as possible is crucial for all parties involved. The government, which pays for the majority of ambulance trips in many parts of the country, wants to save money. And AMR, of course, makes more if it keeps costs down … Los Angeles County mandates that ambulances reach patients within 8 minutes and 59 seconds. To meet this deadline while maintaining profit margins, private companies deploy a thin fleet of ambulances, pay low wages (private-sector EMTs in California make 39% less than their public-sector counterparts) and strategically rearrange the vehicles in their command. AMR’s software suggests that vehicles ‘post’ near busier areas so they’re more likely to encounter transport opportunities. On hectic days, dispatchers maneuver crews around like chess pieces.”

The pandemic has pushed the already thin private services to the brink, overwhelming their already churning health worker force with overpowering stress, especially in dealing with huge caseloads and limited resources, including medical supplies. Even seasoned first-responders struggled to cope with so many people in such desperate shape and trying to do so with such urgency, ProPublica reported.

Here’s what else added to the dispiriting but essential toil: The emergency medical services wages, in a private operation, ran from $15.88 to $17.89 an hour — far less than the government pay that trained personnel could pull down and could stretch into six-figure annual salaries. Health workers in the private firms also know that their enterprises are themselves multibillion-dollar subsidiaries owned by hedge funds worth hundreds of billions.

Patients take a hit, too, with urgent care and transport

By the way, patients and their loved ones have taken an awful hit if they have found themselves needing emergency medical care. The treatment and ground transportation they received too often resulted in “surprise medical bills,” sizable and unexpected charges that insurers declined to cover.

While Congress at the end of 2020 crafted its own surprise ban on most surprise medical bills — extricating patients as hostages in what had been a brutal battle between medical providers and insurers — lawmakers did not tackle ambulance services. That’s because they are so fragmented nationwide, with neighbors in one community potentially getting free or low-cost municipal service, while a few blocks away, private firms charging patients big time.

Policymakers have heard a huge earful about the confusion and soaring costs in this area, including the worrisome rise of patients using ride-share services to get to urgently needed medical services.

Not good. In my practice, I see not only the major harms that patients suffer while seeking medical services but also their huge struggles to access and afford safe, effective, and excellent medical care. This has become an ordeal due to the soaring complexity, uncertainty, and costs of treatments and prescription medications, too many of which turn out to be dangerous drugs.

We have much work to do at many different levels to ensure that ordinary folks can have 100% trust that when they need emergency responses — whether from law enforcement or for medical care and transportation — it will be there for them, at reasonable cost and with excellent services. Most of the folks who serve as first-responders do so with admirable energy, commitment, and capacity.

We need to weed out those who do not. This is true in emergency medical care and law enforcement, including when it unfairly and over zealously targets individuals of color and underserved communities. At the same time, we cannot accept destructive, extremist assaults such as occurred on Jan. 6 in the nation’s capital on the democratic rule of law and law enforcement officers acting responsibly in the line of duty, especially in protection of human life and valued property. Recent months have shown us how divisive and difficult the task will be to ensure all people get treated properly and fairly in difficult circumstance. Doing so is an essential part of what we are about as Americans.